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Drug Category: Dermatological

Medication Class/Individual Agents: Antibiotics

I. Prior-Authorization Requirements

 Topical Antibacterials

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

bacitracin * test  
bacitracin / polymyxin B topical ointment double antibiotic ointment * test  
chlorhexidine gluconate * test  
gentamicin topical cream, ointment test  
hydrogen peroxide * test  
iodine * test  
isopropyl alcohol * test  
mafenide Sulfamylon # test  
mupirocin cream Bactroban PA  
mupirocin nasal ointment Bactroban PA  
mupirocin ointment Centany test  
mupirocin ointment test  
mupirocin powder PA  
neomycin / bacitracin / polymyxin B / hydrocortisone topical ointment Cortisporin test  
neomycin / bacitracin / polymyxin B topical ointment triple antibiotic ointment * test  
neomycin / polymyxin B / hydrocortisone cream Cortisporin test  
povidone * test  
silver sulfadiazine-Silvadene Silvadene # test  
silver sulfadiazine-SSD SSD # test  
silver sulfadiazine-Thermazene Thermazene # test  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

Warnings and Precautions:

  • Contact with eyes should be avoided.
  • Contact with mucosal surfaces should be avoided with mupirocin 2% ointment. Mupirocin 2% nasal ointment is applied into the nostrils.
  • If severe local irritation occurs, product should be discontinued.
  • Prolonged use may result in overgrowth of nonsusceptible microorganisms, including fungi.
  • Mupirocin 2% ointment contains polyethylene glycol. This product should be avoided if large quantities of polyethylene glycol could potentially be absorbed, especially in those with moderate-to-severe renal impairment or open wounds with damaged skin (other formulations do not contain polyethylene glycol).
 

 Vaginal Antibiotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

clindamycin vaginal cream-Cleocin Cleocin # test  
clindamycin vaginal cream-Clindesse Clindesse PA  
clindamycin vaginal suppository Cleocin Vaginal Ovule PA  
metronidazole 0.75% vaginal gel-Metrogel-Vaginal Metrogel-Vaginal # test  
metronidazole 0.75% vaginal gel-Vandazole Vandazole test  
metronidazole 1.3% vaginal gel Nuvessa PA  
sulfanilamide AVC test  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Bacterial vaginosis - Cleocin Vaginal Ovule, Clindesse, Nuvessa
  • Treatment of impetigo or infection - mupirocin cream
  • Eradication/prophylaxis of nasal colonization with methicillin-resistant Staphylococcusaureus (MRSA) in adult patients and health care workers to reduce the risk of infection during an institutional outbreak - Bactroban nasal ointment

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

 

Bactroban nasal ointment for eradication/prophylaxis of nasal MRSA colonization in adult patients and health care workers to reduce the risk of infection during an institutional outbreak

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • request is for a quantity of ≤ 10 grams for 5 days.

 

Cleocin Vaginal Ovule, Clindesse, and Nuvessa

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • if the request is for Nuvessa, the member is ≥ 18 years of age; and
    • an inadequate response, adverse reaction, or contraindication to oral metronidazole tablets or metronidazole 0.75% gel; and
    • an inadequate response, adverse reaction, or contraindication to clindamycin 2% vaginal cream; and
    • appropriate dosing.

 

mupirocin cream for impetigo or infected traumatic lesions

Documentation of the following is required: 

  • an appropriate diagnosis; and
  • medical records documenting an inadequate response, adverse reaction, or contraindication to mupirocin ointment.

 

mupirocin powder

  • Documentation of all the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used. 


Original Effective Date: 07/2005

Last Revised Date: 08/2019


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Last updated 11/15/19